Fillable Form 403-440 - Direct Deposit Authorization Form printable pdf download

Form 403-440 - Direct Deposit Authorization Form

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ACCOUNTING DIVISION

115 S. Andrews Avenue, Room 203 • Fort Lauderdale, Florida 33301 • 954-357-7190 • FAX 954-357-5550

DIRECT DEPOSIT AUTHORIZATION FORM

This form must be completed and returned to Payroll Central by Thursday prior to the end of the pay period.

Employee Information

Employee Name: ___________________________________________ Division: ___________________

Employee Number: _____________________________ SSN (Optional): __________________________

PAYROLL PRIMARY ACCOUNT (Net Pay)

**It is mandatory to complete a RapidPay card form, when cancelling your net pay direct deposit.**

Financial Institution: ____________________________ Start _____

Change _____ Cancel _____

Routing Number: _______________________________ Account Number: ______________________

Checking: ____ **MUST ATTACH A VOIDED CHECK OR AUTHORIZATION FORM**

Savings: ____ **MUST ATTACH AUTHORIZATION FROM FINANCIAL INSTITUTION**

PAYROLL SECONDARY ACCOUNT (Fixed Dollar Amount: $_______________)

Financial Institution: ____________________________ Start _____

Change _____ Cancel _____

Routing Number: _______________________________ Account Number: ______________________

Checking: ____ **MUST ATTACH A VOIDED CHECK OR AUTHORIZATION FORM**

Savings: ____ **MUST ATTACH AUTHORIZATION FROM FINANCIAL INSTITUTION**

**In order to process your direct deposit all required information MUST be attached. If you have more than one secondary

account, an additional form will need to be completed and signed.**

Employee Signature: _________________________________________ Date: _______________________

Signature above signifies agreement with the terms and conditions below.

What to Expect with Direct Deposit:

With Direct Deposit your payment will be credited to your account automatically. You will receive your regular earnings statement listing your gross pay, deductions

and net pay. This authorization is to remain in effect until withdrawn by me in writing with sufficient notice to the County to allow adequate time to effect termination.

Terms and Conditions:

I hereby authorize and request the Board of County Commissioners to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error

to my account at the financial institution named.

Form no. 403-440 (Rev. 03/22/13)

Broward County Board of County Commissioners

Mark D. Bogen • Beam Furr • Dale V.C. Holness • Martin David Kiar • Chip LaMarca • Tim Ryan • Barbara Sharief • Lois Wexler